403 Forbidden

LAWRENCE TOWNSHIP (Mercer County) — It all looked so familiar to Mark Keown. The insurance broker had just helped the family of a severely disabled child find the right insurance policy to cover home health care.

So as he read the March 6 Star-Ledger story about quadriplegic Christopher Heinel, who was in danger of losing his own skilled nursing care because his insurance company suddenly curtailed its policy, Keown knew he had to contact the family.

"I felt 99.9 percent certain there was a solution," he said.

The reason the 57-year-old Mount Arlington man felt so positive was because he had recently discovered that New Jersey law requires insurance carriers, even when they reduce or eliminate policies, to continue to offer a standard plan that provides for unlimited home health care.

"It was a stroke of luck," Keown said, "because I’d already done all the research."

For Heinel and his parents, Keown was "a godsend."

"He was so touched by the story, he wanted nothing," said Jeannette Heinel, Christopher’s mother. "He just felt compelled to help us."

Now 30 years old, Christopher Heinel was 16 when he broke his third, fourth and fifth vertebrae in a collision during a lacrosse game at the Hun School in Princeton Township, paralyzing him from the neck down.

For years, Aetna took care of his skilled nursing needs, which increased several years ago when he developed Type I diabetes and was plagued with a series of life-threatening urinary tract infections.

Last summer, Aetna notified the Heinels, who live with Christopher in Lawrenceville and own their own financial consulting firm, that it was drastically reducing its small employer group coverage.

Instead of the 24 hours of skilled nursing care it had been providing for their son, it would now offer just 60 4-hour visits a year. Forced to find new insurance, the Heinels were approved by AmeriHealth late last year, but its medical director denied Christopher Heinel the 24-hour skilled nursing benefit.

The family appealed, and while they waited a federal judge ordered both Aetna and AmeriHealth to continue 16 hours of skilled nursing care a day.

"It was painful and scary, for sure," said Jeannette Heinel. "It’s your child and you’re afraid for your child."

Late last month an independent review board appointed by the New Jersey Department of Banking and Insurance sided with AmeriHealth’s denial of benefits, although according to the Heinels’ attorney, Tom Cunniff, the board said Christopher Heinel "needed 24-7 care, both custodial and intermittent skilled."

The Heinels were prepared to go back to court when Keown called.

"I have three sons who played high school lacrosse and I felt great compassion when I read their story," he said. "I knew I could help."

Just a month earlier, Keown, on behalf of a client, had asked for similar help from Ellen DeRosa, executive director of the individual health coverage and small employer health benefits program at the state’s Department of Banking and Insurance.

"She’s the foremost authority," Keown said. "It’s not her job to give advice, but if you ask the correct question she’ll give you the answer."

The answer, it turned out, was there all along. Insurance companies make modifications to policies and re-design their plans all the time, Keown said, so it’s difficult to keep up. In Aetna’s most recent guide to small employer insurance policies, the standard plan pertaining to home health care coverage is buried in a 44-page-long list.

Three weeks after Keown contacted the family and set the wheels in motion, the family’s lawyer called.

"Tom said, ‘I have very good news. Aetna is going to include Christopher in their policy.’ " Jeannette Heinel said.

It wasn’t 24-hour coverage, he said, but it was more than they dared hope: As of midnight Tueday, Heinel is now receiving 12 hours of skilled nursing care a day from Aetna.

"It was total relief," Jeannette Heinel said. "It’s amazing that a total stranger stepped up … he was just a wonderful good Samaritan."